MIDIRS Essence > February 2010 > Midwifery News

Maternal death

Originally posted on Feb 2010

Thankfully, maternal deaths are extremely rare in the United Kingdom. This is the result of many years of painstaking work by professionals, who have constantly reviewed their own working and organisational practices to help identify and reduce risk for women.

A midwife finding themselves in the midst of this catastrophic event needs to have a range of tools and structured support at their disposal. If you are involved in an event of this type, you will be required to assist in both formal and informal reviews.

It is usual for a full internal investigation and/or root cause analysis to be conducted, and in some cases an external review or referral to the Coroner’s Office may be required, as well as notification to the Centre for Maternal and Child Enquiries (CMACE).

Reporting a maternal death

There are a number of guidance documents that can be accessed through each Local Supervising Authority/Strategic Health Authority website or through the Local Supervising Authority (UK) Forum website www.midwife.org.uk.

The initial notification to various staff groups and organisations needs to occur as soon as possible. There is a helpful framework available from the above website to ensure that the main notifications are made.

The medical records need to be fully scrutinised and it may be helpful to add retrospective notes whilst events are still fresh in the minds of all attending personnel.

It is usual for each midwife to provide a report about the care that they provided and their involvement in the case. The overall report needs to be quite detailed, and it is helpful for each practitioner to give an overview of the circumstances and events whilst articulating any issues or points of concern. This may relate to staffing, teamwork, current guidelines and procedures, equipment or anything that may have compromised care – or indeed if everything possible had been carried out – that the care was exemplary and there is nothing to learn.

The rippling effect of a maternal death needs to be fully considered and plans for containment and support for other women and families needs to be carefully planned.

After the initial reporting has been carried out there may be a requirement for additional reviews, debriefs, or meetings with the family to go through results of various investigations, for example post-mortem examinations or histology results.

The reporting of the case to CMACE ensures that the case will be fully reviewed, and any learning points will be disseminated through the publication of the triennial report (eg Saving mothers’ lives, Lewis 2007).

If the case is newsworthy, then a statement needs to be drafted for the press and shared with all those involved.

Definitions of a maternal death

Deaths of women while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Direct

Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour, puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above (eg thrombosis, pre-eclampsia, haemorrhage).

Indirect

Deaths resulting from previous existing disease, or disease that developed during pregnancy and which were not due to direct obstetric causes, but which were aggravated by the physiologic effects of pregnancy (eg cardiac problems, malignancies, psychiatric).

Late

Deaths occurring between 42 days and one year after abortion, miscarriage or delivery that are due to direct or indirect maternal causes.

Coincidental

Deaths from unrelated causes which happen to occur in pregnancy or the puerperium (eg road traffic accidents, household accidents).

Key findings of the Saving Mothers’ Lives – Confidential Enquiry 2003-2005

The last triennial report can be located on www.cmace.org.uk and a summary of key findings in both the main report and the executive summary. The most common cause of direct death was thromboembolism, closely followed by pre-eclampsia, genital tract sepsis and amniotic fluid embolism.

Cardiac disease was the most common cause of indirect death which reflects the growing incidence of acquired heart disease in younger women related to less healthy diets, smoking, alcohol and increasing obesity.

In many of the cases reviewed, care provided was hampered by poor interagency working and problems with communication; this included poor teamworking, inappropriate or too short consultations (or too late), lack of sharing of relevant information between health professionals and poor interpersonal skills.

Conclusion

There are many support systems and networks available to midwives and fellow professionals who may find themselves in this scenario.

Whilst these circumstances remain rare it is important for midwives to be prepared for all eventualities. This includes familiarising themselves with the key summary recommendations for good practice and the more practical action checklist found within the triennial report.

Bibliography

Department of Health (2007). Maternity matters: choice, access and continuity of care in a safe service. London: DH.

Department of Health (2009). Obesity general information.

Lewis G ed (2007). Saving mothers' lives: reviewing maternal deaths to make motherhood safer, 2003-2005. The seventh report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH.

Nursing and Midwifery Council (2004). Midwives rules and standards. London: NMC.

Nursing and Midwifery Council The Code: standards of conduct, performance and ethics for nurses and midwives. London: NMC.

World Health Organisation Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva: WHO.

Resources

Centre for Maternal and Child Enquiries - www.cmace.org.uk

LSA Midwifery Officers' Forum - www.midwife.org.uk

Val Beale | LSA Officer | LSA Midwifery Officer (LSAMO) | South West | Photo credit: Rubberball

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